Abstract

OBJECTIVE: To analyze the current evidence on the use of ureteroscopy (URS) and extracorporeal shock wave lithotripsy (ESWL) for the management of obstructing ureteral stones in emergent setting.METHODS: A systematic literature review was performed up to June 2016 using Pubmed and Ovid databases to identify pertinent studies. The PRISMA criteria were followed for article selection. Separate searches were done using a combinations of several search terms: "laser lithotripsy", "ureteroscopy", "extracorporeal shock wave lithotripsy", "ESWL", "rapid", "immediate", "early", "delayed", "late", "ureteral stones", "kidney stones", "renal stones". Only titles related to emergent/rapid/immediate/early (as viably defined in each study) versus delayed/late treatment of ureteral stones with either URS and/or ESWL were considered for screening. Demographics and operative outcomes were compared between emergent and delayed lithotripsy. RevMan review manager software was used to perform data analysis.RESULTS: Four studies comparing emergent (n = 526) versus delayed (n = 987) URS and six studies comparing emergent (n = 356) versus delayed (n = 355) SWL were included in the analysis. Emergent URS did not show any significant difference in terms of stone-free rate (91.2 versus 90.9%; OR 1.04; CI 0.71, 1.52; p = 0.84), complication rate (8.7% for emergent versus 11.5% for delayed; OR 0.94; CI 0.65, 1.36; p = 0.74) and need for auxiliary procedures (OR 0.85; CI 0.42, 1.7; p = 0.85) when compared to delayed URS. Emergent ESWL was associated with a higher likelihood of stone free status (OR 2.2; CI 1.55, 3.17; p < 0.001) and a lower likelihood of need for auxiliary maneuvers (OR 0.49; CI 0.33, 0.72; p < 0.001) than the delayed procedure. No differences in complication rates were noticed between the emergent and delayed ESWL (p = 0.37).CONCLUSIONS: Emergent lithotripsy, either ureteroscopic or extracorporeal, can be offered as an effective and safe treatment for patients with symptomatic ureteral stone. If amenable to ESWL, based on stone and patient characteristics, an emergent approach should be strongly considered. Ureteroscopy in the emergent setting is mostly reserved for distally located stones. The implementation of these therapeutic approaches is likely to be dictated by their availability.

Comments
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From this review of comparative studies on emergent and delayed SWL, the authors carried out a meta-analysis. In the six articles that provided data of sufficient quality it is clear that emergent/early SWL was associated with a much better outcome in terms of stone-free rates than was the case with delayed SWL.

The complications and need of auxiliary procedures were less than with delayed SWL. These findings are in agreement with my personal experience. The bottom-line is that when SWL is intended for removal of ureteral stones, the clinical organization should allow for treatment as early as possible after diagnosis.
Patients in whom SWL is carried out early because of intractable pain often describe relief of pain already during the SWL procedure.

From this review of comparative studies on emergent and delayed SWL, the authors carried out a meta-analysis. In the six articles that provided data of sufficient quality it is clear that emergent/early SWL was associated with a much better outcome in terms of stone-free rates than was the case with delayed SWL.
The complications and need of auxiliary procedures were less than with delayed SWL. These findings are in agreement with my personal experience. The bottom-line is that when SWL is intended for removal of ureteral stones, the clinical organization should allow for treatment as early as possible after diagnosis.
Patients in whom SWL is carried out early because of intractable pain often describe relief of pain already during the SWL procedure.